Paediatric Surgical Outreach to Papua New Guinea: Initial Experience

This is a report of our early experience in establishing a Paediatric surgical outreach program to Papua New Guinea (PNG) to build capacity and improve care. A Paediatric surgical outreach mission was initiated about 4 years ago in collaboration with Singhealth and PNG along with the multidisciplinary team of health care professionals from Cardiology, Cardiothoracic Surgery, Orthopaedics, Urology, Plastics and Anaesthesia. On each mission trip of 4 - 7 days duration, Singhealth doctors supervise or perform surgeries for complex cases, conduct patient consultations and give lectures to impart knowledge and transfer skills to the local health care community in PNG. In addition, a 6 - 12 months training program in Singapore for PNG doctors has been started. For complex cases which cannot be managed in PNG, there is provision for transfer of patients to Singapore under KKROK fund for further treatment. So far 4 mission trips have been conducted in past 4 years for paediatric surgical unit in Port Moresby General Hospital of PNG focussing on teaching and training of local Paediatric surgeons. Based on evaluation of the Singhealth medical team, there is severe shortage of medical manpower, surgical skill and specialised expertise. Due to lack of intensive care facility, adequate medications and proper medical equipment in the hospital, there are many conditions being left untreated causing high morbidity and mortality among infants and neonates. Such humanitarian work inspires Singhealth towards its global health mission of promoting health equity in responding to the medical needs of PNG through training and leveraging on strength through partnership. In addition, our doctors gain invaluable learning from the exposure, hone their skill as they treat a diversity of cases and are innovative in their treatment options by working in an environment with limited resources.


Introduction
Papua New Guinea (PNG) is a young nation that became independent in 1975 [1]. It is located in Oceania and is composed of the eastern half of the island of Guinea. With a population of nearly 8 million, and more than 800 native languages, cultures and traditions, its main economic activity is farming and harvesting natural resources. The nation is divided into four regions; namely the New Guinea Islands region, Northern region (Momase), Highlands region and Southern region (Papua). It constitutes a total of 22 provinces. The main referral and teaching Hospital (Port Moresby General Hospital) is located in the southern region.
Healthcare in PNG is primarily provided by the government. The country spends about 4.5% of its gross domestic product on health [2]. A significant portion of this comes from international donations. The doctor to patient ratio is 1:17,068. Apart from there being an absolute shortage of physicians, there is also an issue of uneven distribution of healthcare resources [3] [4] [5]. Nearly 85% of the population lives in rural areas, but only 50% of the doctors work outside the capital Port Moresby [6].

Paediatric Surgery at PNG
General paediatric surgical service were delivered by the general surgeons or by overseas paediatric surgeons during ad hoc visits for many years, until the first Papua New Guinea paediatric surgeon was trained and graduated from the

Initiation of the Outreach Program
With the limited capacity and needs in mind, an initiative was launched in the year 2014. The main aim of this initiative was to create an outreach program whereby paediatric surgeons from KK Hospital would share their skills to build capacity and improve care in paediatric surgery in PNG.
The initiative was collaboration between Singhealth International Collabora-

Program Structure
The program was structured to be a series of visits by a multidisciplinary team

Challenges and Opportunities
The outreach program identified many opportunities to contribute to skills development in PNG. As the young nation strives to improve the care for its people, such initiatives can play an important role in helping aspiring trainees in acquiring skill sets that would go a long way in addressing the needs of their communities. The team at PMGH was enthusiastic and eager to maximize their learning. Apart from core surgical capacity development, there is also room for improvement in the support system for the paediatric surgeons.
The program has not been without a fair share of challenges. These can be grouped as being related to the pathology, operational issues and specific areas of need. In a way these also represent opportunities for organizations to help in capacity building. 2) Operational issues: The most important issue is that of limited facilities.
The operating room size, equipment and layout were challenging, as was the availability of instruments for paediatric surgery, as opposed to general adult surgical instruments. Radiological and pathology support was also noted to be very limited-primarily because of resource constraints at PMGH.
For operated cases, there is minimal ICU support despite best efforts of the nursing department. There is scope for development of neonatal and children's ICU facilities.
Another aspect is the limitation of skilled manpower. There is a definite need to increase the number of nurses and doctors with a defined formal training program. Once a critical mass of well-trained healthcare staff is available, a multidisciplinary approach would be required for holistic care of children presenting with surgical conditions.
HIV prevalence rates continue to be high in PNG. As such, preoperative screening is not available and needs to be instituted to minimize the risks to the surgeons and nurses.

Insights Gained during the Trips
Working outside the comfort zone of one's daily practice is not easy. At PMGH, we realized that working with minimal facilities and limited resources forces one to adapt and improvise and innovate based on the needs that arise. Hence they have recorded case of neonatal surgical case, survivor cases such as gastroschisis, tracheo-eosophageal fistula and all anorectal anomallies requiring colostomy.
This is a very meaningful insight that we gained from our trips. Besides this, we appreciated the need to plan properly, manage time realistically and anticipate unexpected developments along the way. To perform in the best possible way, we relied on team work and close coordination within the team, and also with our gracious hosts.
So despite the fact that there were resource constraints, the trips so far have been unanimously perceived as being very insightful and gratifying.

Outcomes and Future Plans
By the end of the fourth trip, the surgical team at PMGH was able to manage some of the index paediatric surgical cases much more confidently. This was achieved by hands-on surgical co-management of cases during the trips. Further, a 6 -12 months fellowship for trainee paediatric surgeons from PMGH has also been instituted.
Looking forward, there are plans to train other professionals as well. These include other key members involved in the management of paediatric surgical cases, namely paediatric anaesthetists, nurses and neonatologists. There is also a realization for need to train personnel in proper administration of total parenteral nutrition. With a strong team in place, the outcomes are likely to be better.
Apart from manpower training, there are also considerations for building in-